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� <br />Date�Q= c,a'� <br />Application For <br />PUBLiC WORKS PERMIT <br />Print or Type Only <br />Pu�bc Woiks Pmmil vp �� � � <br />BI4B. �c�l. + (1�/ / � /� <br />PubhcWo�kSFco 5 <br />Tc' •I Feo <br />Less AOo� Fue Paid S <br />BaiancaDue 5 <br />�r��r.�n rryr IA1(Y��n. $I�S ��Prn(P,�H U�ii .Evprei% �J�zo3 347-.S�j�n <br />Owner Mailing Address City Zip � Phone <br />nt <br />Describe Proposed Work <br />Project P,dtlress (il known) <br />City Zip <br />Altach lour (4) copies of plans lor proposed work - Draw to scale and note the tollowing as applicable: <br />• Property Lines • Centedine of stree� <br />• Outline and dimensions of all exisling and e Indicate North <br />proposed structures on the lot • Show any proposed grading changes <br />• Existing and proposed u�ilities • Show measurements <br />PERMITfONDITIONS <br />1. All calls tor inspection shall be made 24 hrs. in advance- phone 259•8810. <br />2. All work shall be pP�'ormed in accorAance with this permit and current Ciry of Everelt Design and Construction <br />Slandards and Spec:dications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1•800•424•5555. <br />/UOT ,��� <br />.��/�c$'B <br />�` <br />Approved for Consiruction Date <br />FINAL INSPECTION Date <br />Approved as ConStructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Street <br />Everelt. WA 98201 <br />�hone:259-8810 <br />ACKNOWLEDGEMENT OF CONDI'iIONS <br />W <br />H <br />N <br />f �' <br />� <br />� <br />� <br />� <br />� <br />� <br />a <br />The undersigned oH�ner/applicant hereby agrees to holtl and save harm- <br />less 1he City of Everett Irom any and all claims lor damages, cosls, <br />expenses, or causes of action tlial may arise because of inslallation <br />and mzintenance of the improvement �r other right-oi-way use hereto <br />applied lor and further agrees lo remove same upon notice from the <br />Ciry and to replace puGlic property damaged thereby. <br />Signature of Applicant Dale <br />WORK AUTIiORIZED BY THIS PERMIT MUST BE STARTEO WITHIN <br />180 DAYS OF GATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY 8[ <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON �HIS <br />PROJ[CT OVER 90 �AYS DURATION. <br />